Mental Health and Substance Abuse Services Substance Abuse Day Treatment
DIVISION OF HEALTH CARE FINANCING WISCONSIN MEDICAID AND BADGERCARE PROVIDER SERVICES 6406 BRIDGE ROAD MADISON WI 53784 Jim Doyle Governor Telephone: 800-947-9627 Helene Nelson State of Wisconsin 608-221-9883 dhfs.wisconsin.gov/medicaid Secretary Department of Health and Family Services dhfs.wisconsin.gov/badgercare DATE: March 1, 2006 M E M O R A N D U M TO: FROM: SUBJECT: Wisconsin Medicaid-Certified Substance Abuse Day Treatment Providers Mark Moody, Administrator Division of Health Care Financing Wisconsin Medicaid Mental Health and Substance Abuse Services Handbook with Substance Abuse Day Treatment section The Division of Health Care Financing is pleased to provide a copy of two sections of the Mental Health and Substance Abuse Handbook. The General Information section of the handbook articulates current Medicaid policies found in Wisconsin Administrative Code, HFS 101-108, as they apply to mental health and substance abuse services. The Substance Abuse Day Treatment Services section incorporates current Medicaid substance abuse policy information into a single reference source. This section replaces Part H, Division IV, the AODA Day Treatment handbook (issued July 1989), and the following service-specific Wisconsin Medicaid and BadgerCare Updates: The July 2003 Update (2003-78), titled Changes to local codes, paper claims, and prior authorization for substance abuse day treatment services as a result of HIPAA. The April 2004 Update (2004-34), titled Medical Record Documentation Requirements for Mental Health and Substance Abuse Services. The December 2004 Update (2004-88), titled Coverage of Mental Health and Substance Abuse Services Provided Via Telehealth. The January 2005 Update (2005-08), titled Wisconsin Medicaid Accepting Prior Authorization Requests Via the Web for Additional Service Areas. All-Provider Publications Providers are reminded to retain their all-provider publications. The revised Mental Health and Substance Abuse Services Handbook sections does not replace these publications. Additional Copies of Publications The Wisconsin Medicaid Web site, dhfs.wisconsin.gov/medicaid/, contains additional information for all Medicaid providers, service-specific information, and electronic versions of the Mental Health and Substance Abuse Services Handbook and the All-Provider Handbook. Providers who have questions about the information in this handbook may call Provider Services at (800) 947-9627 or (608) 221-9883.
Contacting Wisconsin Medicaid Web Site dhfs.wisconsin.gov/ The Web site contains information for providers and recipients about the following: Program requirements. Publications. Forms. Maximum allowable fee schedules. Professional relations representatives. Certification packets. Available 24 hours a day, seven days a week Automated Voice Response System (800) 947-3544 (608) 221-4247 The Automated Voice Response system provides computerized voice responses about the following: Recipient eligibility. Prior authorization (PA) status. Claim status. Checkwrite information. Available 24 hours a day, seven days a week Provider Services (800) 947-9627 (608) 221-9883 Available: Resolving claim denials. Provider certification. Correspondents assist providers with questions about the following: Clarification of program requirements. Recipient eligibility. Division of Health Care Financing Electronic Data Interchange Helpdesk 8:30 a.m. - 4:30 p.m. (M, W-F) 9:30 a.m. - 4:30 p.m. (T) Available for pharmacy services: 8:30 a.m. - 6:00 p.m. (M, W-F) 9:30 a.m. - 6:00 p.m. (T) (608) 221-9036 e-mail: wiedi@dhfs.state.wi.us Correspondents assist providers with technical questions about the following: Electronic transactions. Companion documents. Provider Electronic Solutions software. Available 8:30 a.m. - 4:30 p.m. (M-F) Web Prior Authorization Technical Helpdesk (608) 221-9730 Correspondents assist providers with Web PA-related technical questions about the following: User registration. Submission process. Passwords. Available 8:30 a.m. - 4:30 p.m. (M-F) Recipient Services (800) 362-3002 (608) 221-5720 Correspondents assist recipients, or persons calling on behalf of recipients, with questions about the following: Recipient eligibility. General Medicaid information. Finding Medicaid-certified providers. Resolving recipient concerns. Available 7:30 a.m. - 5:00 p.m. (M-F)
TTable of Contents Preface... 3 Provider and Recipient Information... 5 Provider Certification... 5 Copayment... 5 Managed Care Coverage for Day Treatment Services... 5 Covered Services... 7 Program Admission Requirements... 7 Sessions Requirements... 7 Covered Services... 7 Services Provided Via Telehealth... 8 Reimbursement Limitations... 8 Noncovered Services... 8 Special Circumstances... 8 Documentation Requirements... 8 Prior Authorization... 9 Services Requiring Prior Authorization... 9 Prior Authorization Criteria... 9 Procedures for Obtaining Prior Authorization... 9 Backdating Substance Abuse Prior Authorization Requests... 9 Claims Submission... 11 Coordination of Benefits... 11 Diagnosis Codes... 11 Procedure Codes... 11 Place of Service Codes... 11 837 Health Care Claim: Professional... 11 CMS 1500... 11 Reimbursement... 12 Appendix... 13 1. Medicaid Certification Requirements for Substance Abuse Day Treatment Services... 15 2. Allowable Procedure Code and Modifiers for Substance Abuse Day Treatment Services... 17 3. Allowable Place of Service Codes for Substance Abuse Day Treatment Services... 19 4. Prior Authorization Request Form (PA/RF) Completion Instructions for Substance Abuse Day Treatment Services... 21 5. Sample Prior Authorization Request Form (PA/RF) for Substance Abuse Day Treatment Services... 25 PHC 1336
6. Treatment Criteria for Substance Abuse Day Treatment (Adult): Severity of Illness... 27 7. Treatment Criteria for Substance Abuse Day Treatment Program (Adolescent): Severity of Illness... 29 8. Treatment Criteria for Substance Abuse Day Treatment Program (Adult and Adolescent): Intensity of Service... 31 9. Prior Authorization/Substance Abuse Day Treatment Attachment (PA/SADTA) Completion Instructions... 33 10. Prior Authorization/Substance Abuse Day Treatment Attachment (PA/SADTA) (for photocopying)... 37 11. CMS 1500 Claim Form Instructions for Substance Abuse Day Treatment Services... 43 12. Sample CMS 1500 Claim Form for Substance Abuse Day Treatment Services... 49 13. Sample CMS 1500 Claim Form for Substance Abuse Day Treatment Services, Biller Only Providers... 51 14. Mental Health and Substance Abuse Services Documentation Requirements... 53 Index... 55
Preface Wisconsin Medicaid and BadgerCare mental health and substance abuse services publications apply to fee-forservice Medicaid providers. The information in these publications apply to Medicaid and BadgerCare programs for recipients on fee-for-service Medicaid. Medicaid is a joint federal and state program established in 1965 under Title XIX of the federal Social Security Act. Wisconsin Medicaid is also known as the Medical Assistance Program, WMAP, MA, Title XIX or T19. BadgerCare extends Medicaid coverage through a Medicaid expansion under Titles XIX and XXI. The goal of BadgerCare is to fill the gap between Medicaid and private insurance without supplanting or crowding out private insurance. BadgerCare recipients receive the same health benefits as Medicaid recipients, and their health care is administered through the same delivery system. sections: Refer to the Online Claims Handbook Information. Coordination of Benefits. Wisconsin Medicaid and BadgerCare are administered by the Department of Health and Family Services (DHFS). Within the DHFS, the Division of Health Care Financing (DHCF) is directly responsible for managing Wisconsin Medicaid and BadgerCare. Unless otherwise specified, all information contained in this and other Medicaid publications pertains to services provided to recipients who receive care through fee-forservice. Refer to the Managed Care section of the All- Provider Handbook for information about statecontracted managed care organizations. Substance Abuse Day Treatment Section The information in the Substance Abuse Day Treatment section of this Mental Health and Substance Abuse Handbook applies to Division of Disability and Elder Services, Bureau of Quality Assurance-certified substance abuse day treatment service programs. Substance abuse day treatment providers should refer to the All-Provider Handbook, the General Information section of this handbook, and this section to find answers to policy-related questions. All-Provider Handbook All Medicaid-certified providers receive a copy of the All-Provider Handbook, which includes the following Certification and Ongoing Responsibilities. Covered and Noncovered Services. Informational Resources. Managed Care. Prior Authorization. Recipient Eligibility. Providers are required to refer to the All-Provider Handbook for more information about these topics. Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 3
Wisconsin Medicaid and BadgerCare Web Sites Publications (including provider handbooks and Wisconsin Medicaid and BadgerCare Updates), maximum allowable fee schedules, telephone numbers, addresses, and more information are available on the following Web sites: dhfs.wisconsin.gov/medicaid/. dhfs.wisconsin.gov/badgercare/. Publications Medicaid publications apply to both Wisconsin Medicaid and BadgerCare. Publications interpret and implement the laws and regulations that provide the framework for Wisconsin Medicaid and BadgerCare. Medicaid publications provide necessary information about program requirements. Legal Framework The following laws and regulations provide the legal framework for Wisconsin Medicaid and BadgerCare: Federal Law and Regulation: Law United States Social Security Act; Title XIX (42 US Code ss. 1396 and following) and Title XXI. Regulation Title 42 CFR Parts 430-498 and Parts 1000-1008 (Public Health). Wisconsin Law and Regulation: Law Wisconsin Statutes: 49.43-49.499 and 49.665. Regulation Wisconsin Administrative Code, Chapters HFS 101-109. Laws and regulations may be amended or added at any time. Program requirements may not be construed to supersede the provisions of these laws and regulations. 4 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006
WWisconsin Medicaid strongly recommends that providers verify the recipient s current enrollment in an MCO before providing services. Provider and Recipient Information PProvider Certification To be reimbursed for providing substance abuse day treatment services to Medicaid recipients, a provider is first required to be certified by the Department of Health and Family Services (DHFS), Division of Disability and Elder Services (DDES) for substance abuse day treatment under HFS 75.12, Wis. Admin. Code. For information regarding this certification, write to the following address: Division of Disability and Elder Services Bureau of Quality Assurance Program Certification Unit 2917 International Ln Ste 300 Madison WI 53704 (608) 243-2025 A provider ARCHIVAL meeting DHFS, DDES certification USE ONLY may initiate Medicaid substance abuse day treatment provider certification, as outlined HFS 105.23, Wis. Admin. Code, by doing one of the following: 1. Downloading mental health agency certification materials from the Medicaid Web site. 2. Calling Provider Services at (800) 947-9627 or (608) 221-9883. 3. Writing to the following address: Wisconsin Medicaid Provider Maintenance 6406 Bridge Rd Madison WI 53784-0006 Refer to the General Information section of this handbook for more information about provider certification, provider numbers, and provider responsibilities. Refer to the Certification and Ongoing Responsibilities section of the All-Provider Handbook for additional information. Copayment Providers are prohibited from collecting copayment from recipients receiving substance abuse day treatment services. Managed Care Coverage for Day Treatment Services State-contracted managed care organizations (MCOs) cover substance abuse day treatment services. Recipients enrolled in all statecontracted MCOs must receive substance abuse day treatment services through the MCO. Providers should check with the recipient s MCO for further information on coverage. Wisconsin Medicaid strongly recommends that providers verify the recipient s current enrollment in an MCO before providing services. Claims submitted to Wisconsin Medicaid for substance abuse day treatment services covered by MCOs will be denied. Provider/Recipient Information Refer to Appendix 1 of this section for more information about certification. Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 5
Provider/Recipient Information 6 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006
Covered Services The Substance Abuse Day Treatment section of the Mental Health and Substance Abuse Services Handbook contains information for providers of substance abuse day treatment services. scheduled number of sessions per day and week, with each recipient generally receiving a minimum of 12 hours of counseling per week and/or a minimum of 60 hours within a sixweek period of time. W Wisconsin Medicaid reimburses the first three hours of assessment and evaluation per recipient, per provider in a calendar year regarding the need for, and ability to benefit from, substance abuse day treatment. According to HFS 101.03(12m), Wis. Admin. Code, substance abuse day treatment means alcohol and other drug abuse treatment services provided by a provider certified under HFS 105.25, Wis. Admin. Code, to a recipient who, in the clinical judgment of a qualified treatment professional, is experiencing a problem with alcohol or other drugs and is willing to receive intensive services of a prescribed duration. These services may include assessment and evaluation, treatment planning, group and individual counseling, recipient education when necessary for effective ARCHIVAL treatment, and rehabilitative USE services ONLY to ameliorate or remove the disability and Refer restore effective to functioning. the Online Handbook Program for Admission current policy Requirements For admission to a substance abuse day treatment program, a recipient must be willing to participate; be detoxified from drugs or alcohol; have the ability to function in a semicontrolled, medically supervised environment; have a demonstrated need for structure and intensity of treatment that is not available in outpatient treatment; and be willing to participate in aftercare upon completion of treatment. Sessions Requirements A substance abuse day treatment service is a medically monitored, nonresidential substance abuse treatment service that consists of regularly scheduled sessions that may include individual and/or group counseling and case management, provided under the supervision of a physician. Services are provided in a Covered Services A covered service is a service, item, or supply for which Medicaid reimbursement is available when all program requirements are met. For a covered service to meet program requirements, the service must be provided by a qualified Medicaid-certified provider to an eligible recipient. In addition, the service must meet all applicable program requirements, including, but not limited to, medical necessity, prior authorization (PA), claims submission, prescription, and documentation requirements. The following services are covered under substance abuse day treatment: Assessment. Wisconsin Medicaid reimburses the first three hours of assessment and evaluation per recipient, per provider in a calendar year regarding the recipient s need for, and ability to benefit from, substance abuse day treatment. Substance abuse day treatment. Wisconsin Medicaid reimburses for intensive, short-term substance abuse treatment provided in a substance abuse day treatment program certified under HFS 105.25, Wis. Admin. Code, for recipients who need and want day treatment services. Refer to the Covered and Noncovered Services section of the All-Provider Handbook for more information about covered services, medical necessity, services that are not separately reimbursable, and emergency services. Covered Services Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 7
Covered Services Services Provided Via Telehealth Individual substance abuse day treatment services may be provided via Telehealth. Refer to the General Information section of this handbook for information about Telehealth requirements and claims submission. Reimbursement Limitations Wisconsin Medicaid does not reimburse the following services or circumstances in accordance with HFS 107.13(3m)(c), Wis. Admin. Code: Substance abuse day treatment services in excess of five hours per day are not reimbursable. Substance abuse day treatment services may not be billed as psychotherapy, substance abuse outpatient treatment, case management, occupational therapy or any other service modality except substance abuse day treatment. Reimbursement for substance abuse day treatment services may not include time devoted to meals, rest periods, transportation, recreation, or entertainment. Reimbursement for substance abuse day treatment assessment for a recipient is limited to three hours in a calendar year. Additional assessment hours shall be counted toward the mental health outpatient dollar or hour amount under HFS 107.13(2)(a)6, Wis. Admin. Code, before PA is required or the substance abuse outpatient dollar or hour limit under HFS 107.13(3)(a)4, Wis. Admin. Code, before PA is required. Noncovered Services The following services are not covered by Wisconsin Medicaid, in accordance with HFS 107.13(3m)(d), Wis. Admin. Code: Collateral interviews and consultations, except as provided in HFS 107.06(4)(d), Wis. Admin. Code. Time spent in the substance abuse day treatment setting by affected family members of the recipient. Substance abuse day treatment services billed under any other Medicaid service category, including substance abuse outpatient services, psychotherapy, occupational therapy, or case management. Substance abuse day treatment services which are primarily recreational or which are provided in non-medically supervised settings. These include, but are not limited to, sports activities, exercise groups, and activities such as crafts, leisure time, social hours, trips to community activities, and tours. Services provided to a substance abuse day treatment recipient which are primarily social or educational in nature. Educational sessions are covered as long as these sessions are part of an overall treatment program and include group processing of the information provided. Prevention or education programs provided as an outreach service or as case-finding. ARCHIVAL Day treatment USE provided ONLY in the recipient s home. Special Circumstances for current The following requirements policy apply specifically to substance abuse day treatment services: All substance abuse day treatment services require a physician prescription/ order. Wisconsin Medicaid reimburses the provision of services. Documenting the services provided is part of the provision of services. Documentation Requirements Refer to Appendix 14 of this section for documentation requirements for all mental health and substance abuse service providers, including substance abuse day treatment providers. For additional information regarding documentation requirements, refer to the General Information section of this handbook. All substance abuse day treatment services require a physician prescription/order. 8 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006
Prior Authorization WWhen assessing recipients who are 18 to 21 years old, providers are to use either the adolescent or adult criteria, depending on the individual recipient s circumstances. Providers are required to obtain prior authorization (PA) for the substance abuse day treatment services specified in this chapter. Authorization for these services must be received prior to providing the services. Refer to the General Information section of this handbook for general PA requirements. For more information about general PA forms and attachments and submitting PA requests, refer to the Prior Authorization section of the All-Provider Handbook. Services Requiring Prior Authorization Prior authorization is not required for the substance abuse assessment, the limit for which is three hours per recipient, per provider in a calendar ARCHIVAL year. USE ONLY Refer Prior authorization to the is required Online before providinghandbook any substance abuse day treatment services to or (608) 221-9883. a recipient following for the current assessment. policy Prior Authorization Criteria Prior authorization criteria for intensity of treatment and severity of illness have been developed for substance abuse day treatment by Wisconsin Medicaid and substance abuse providers. Appendices 6, 7, and 8 of this section contain treatment criteria for substance abuse day treatment services for adults and adolescents. When assessing recipients who are 18 to 21 years old, providers are to use either the adolescent or adult criteria, depending on the individual recipient s circumstances. Providers are required to refer to the appropriate treatment criteria when requesting PA. The criteria illustrate the factors that will be used in determining whether substance abuse day treatment is considered medically necessary by Wisconsin Medicaid. Wisconsin Medicaid reviews and adjudicates PA requests on a case-by-case basis. It is therefore essential that adequate, explicit clinical information be provided on each PA request. Procedures for Obtaining Prior Authorization Providers are required to submit both the Prior Authorization Request Form (PA/RF), HCF 11018, and the Prior Authorization/Substance Abuse Day Treatment Attachment (PA/ SADTA), HCF 11037, for substance abuse day treatment services. The completion instructions and a completed sample PA/RF are located in Appendices 4 and 5 of this section. The PA/RF can be obtained by contacting Provider Services at (800) 947-9627 The completion instructions and a copy of the PA/SADTA are located in Appendices 9 and 10 of this section for photocopying and may also be downloaded from the Medicaid Web site. Backdating Substance Abuse Prior Authorization Requests In certain cases, it is medically necessary to start a recipient in substance abuse day treatment within a short period of time following the initial assessment or completion of detoxification. Wisconsin Medicaid allows backdating of substance abuse day treatment PA requests up to five working days prior to the initial date that Wisconsin Medicaid receives the request, as long as backdating procedures are followed. Prior Authorization Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 9
Refer to the General Information section of this handbook for backdating procedures. Refer to the Prior Authorization section of the All-Provider Handbook for information on other circumstances affecting PA, such as determination of grant dates and service interruptions. Prior Authorization 10 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006
H Healthcare Common Procedure Coding System (HCPCS) codes are required on all substance abuse day treatment claims. CTo receive reimbursement, claims and adjustment requests must be received by Wisconsin Medicaid within 365 days of the date of service (DOS). To receive reimbursement for services that are allowed by Medicare, claims and adjustment requests for coinsurance, copayment, and deductible must be received by Wisconsin Medicaid within 365 days of the DOS, or within 90 days of the Medicare processing date, whichever is later. Claims Submission For more information about exceptions to the claims submission deadline, Medicaid remittance information, adjustment requests, and returning overpayments, refer to the Claims Information section of the All- Provider Handbook. Coordination ARCHIVAL of Benefits USE ONLY Refer With few exceptions, to the Wisconsin Online Medicaid ishandbook the payer of last resort for any Medicaidcovered service. Therefore, the provider is required to make a reasonable effort to exhaust all existing other health insurance sources before submitting claims to Wisconsin Medicaid or to state-contracted managed care organizations. Refer to the Coordination of Benefits section of the All-Provider Handbook for more information about services that require other health insurance billing, exceptions, claims submission procedures for recipients with other health insurance, and the Other Coverage Discrepancy Report, HCF 1159. Diagnosis Codes All diagnoses must be from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding structure. Claims received without an allowable ICD-9-CM code are denied. Refer to Appendix 2 of this section for a list of allowable diagnosis code ranges for substance abuse day treatment services. Procedure Codes Healthcare Common Procedure Coding System (HCPCS) codes are required on all substance abuse day treatment claims. Claims or adjustments received without a HCPCS code are denied. Refer to Appendix 2 of this section for the allowable procedure code and modifiers. Place of Service Codes Allowable place of service codes for substance abuse day treatment are included in Appendix 3 of this section. 837 Health Care Claim: Professional Providers are encouraged to submit claims electronically since electronic claims submission usually reduces claim errors. Claims for substance abuse day treatment services may be submitted using the 837 Health Care Claim: Professional transaction except when submitting claims that require additional documentation. In these situations, providers are required to submit paper claims. Refer to the Informational Resources section of the All-Provider Handbook for more information about electronic transactions. CMS 1500 Paper claims for substance abuse day treatment services must be submitted using the CMS 1500 claim form dated 12/90. Wisconsin Medicaid denies claims for substance abuse day treatment services submitted on any paper claim form other than the CMS 1500. Claims Submission Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 11
Wisconsin Medicaid does not provide the CMS 1500 claim form. The form may be obtained from any federal forms supplier. Refer to Appendix 11 of this handbook for claim form instructions for substance abuse day treatment services. Appendices 12 and 13 are samples of claims for substance abuse day treatment services. Reimbursement Certified substance abuse day treatment providers are reimbursed at the lesser of the provider s usual and customary charge or the maximum allowable fee established by the Department of Health and Family Services. The maximum allowable fee is a comprehensive hourly rate that is paid for any allowable day treatment service regardless of which staff person provided the service or whether the service was a group or individual service. Hospitals that have certified substance abuse day treatment programs should not include the Medicaid charges associated with the day treatment cost center in the Medicare/ Medicaid Cost Report. Substance abuse day treatment services are not considered hospital outpatient services. HHospitals that have certified substance abuse day treatment programs should not include the Medicaid charges associated with the day treatment cost center in the Medicare/Medicaid Cost Report. Claims Submission 12 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006
Appendix Appendix Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 13
Appendix 14 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006
Appendix 1 Medicaid Certification Requirements for Substance Abuse Day Treatment Services This appendix outlines Wisconsin Medicaid certification requirements for substance abuse day treatment service providers. Prior to obtaining Wisconsin Medicaid certification, substance abuse day treatment providers are required to be certified by the Department of Health and Family Services (DHFS), Division of Disability and Elder Services (DDES), Bureau of Quality Assurance (BQA). County/tribal social or human services agencies that request billing-only status do not need to be certified by the DDES. The following terms are used in the table: Agency Providing the Service The agency whose staff actually performs the service. Agency Only Allowed to Bill the Service The agency that submits claims to Wisconsin Medicaid for the service. This agency does not perform the service but contracts with a provider to perform the service on the billing agency s behalf. The provider may be a certified program within the billing agency. Only a county/tribal social or human services agency can be a billing agency. The following table lists required provider numbers and definitions for agencies providing mental health and substance abuse services. Type of Provider Number Billing/Performing Provider Number Billing-Only Provider Number Type of Agency Agency Providing the Service Agency Only Allowed to Bill the Service Definitions for Provider Numbers Definition Issued to providers to allow them to identify themselves on claims as either the biller of services or the performer of services. ARCHIVAL services when contracting with USE a service performer. ONLY Refer to the Certification Online Requirements Handbook Specific Certification Division of Disability and Elder Services/Bureau of Quality Assurance The agency is required to obtain a Wisconsin DHFS certificate to provide substance abuse day treatment services as authorized under HFS 75.12, Wis. Admin. Code. Not required Issued to county/tribal social or human services agencies to allow them to serve as the biller of Wisconsin Medicaid The agency is required to do the following: Have a DDES, BQA certificate on file. Complete and submit a Mental Health and Substance Abuse Agency Certification Packet. The agency is required to complete and submit a Mental Health and Substance Abuse Agency Certification Packet to be a billingonly provider for substance abuse day treatment services. An allowable Medicaid performing provider is required to perform the service. Section of the Medicaid Mental Health/ Substance Abuse Agency Packet to Be Completed Substance Abuse Day Treatment Substance Abuse Day Treatment County/ Tribal Social or Human Services Agency? No Yes Type of Provider Number Assigned Day treatment (mental health/ substance abuse) billing/ performing provider number Day treatment (mental health/ substance abuse) billing provider number Appendix Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 15
Appendix 16 Wisconsin Medicaid and BadgerCare! dhfs.wisconsin.gov/medicaid/! April 2006
Appendix 2 Allowable Procedure Code and Modifiers for Substance Abuse Day Treatment Services The following table lists the Healthcare Common Procedure Coding System (HCPCS) procedure code and modifiers that substance abuse day treatment providers are required to use when requesting prior authorization and submitting claims. HCPCS Code H2012 Description Behavioral health day treatment, per hour Program Modifier Code HF Substance abuse program Service Modifier Code Allowable ICD-9-CM Diagnosis Codes* None 303.90-303.91 304.00-304.01 304.10-304.11 304.20-304.21 304.30-304.31 304.40-304.41 304.50-304.51 304.60-304.61 304.70-304.71 304.80-304.81 304.90-304.91 305.00-305.01** Telehealth Services Covered? 305.20-305.21** 305.30-305.31** 305.40-305.41** Refer to the Online 305.50-305.51** Handbook 305.60-305.61** for current 305.70-305.71** policy Behavioral health day treatment, per hour HF Substance abuse program U6 Assessment 305.80-305.81** 305.90-305.91** Diagnosis code required, no restrictions For individual services only Prior Authorization Required? * ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification. The list of ICD-9-CM diagnosis codes for substance abuse day treatment is inclusive. However, not all Medicaid-covered substance abuse day treatment services are appropriate or allowable for all diagnoses. Wisconsin Medicaid bases approval of services on a valid diagnosis, acceptable substance abuse day treatment practice, and clear documentation of the probable effectiveness of the proposed service. ** An abuse diagnosis, as the only and primary diagnosis, is appropriate only for children or adolescents for substance abuse day treatment services. Yes Yes No Appendix Mental Health and Substance Abuse Services Handbook Substance Abuse Day Treatment! April 2006 17